A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?

Command hallucinations.

Impaired memory.

Inappropriate speech patterns.

Rapid mood swings.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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Correct Answer is C

Explanation

Choice A rationale:

Explaining implied consent to the client's family is not the appropriate action in this situation. Implied consent typically refers to situations where consent is assumed due to the client's actions or circumstances, but it is not applicable when a client has been declared legally incompetent. The nurse should seek consent from a legally authorized representative, such as a guardian, in this case.

Choice B rationale:

Contacting the facility social worker is a good step to take when dealing with complex legal and ethical situations. However, the nurse's primary responsibility is to ensure that the client's legally authorized representative provides informed consent. This means that the client's guardian should be the one to sign the consent form, rather than the social worker.

Choice D rationale:

Asking the charge nurse to obtain informed consent is not the appropriate action because obtaining consent is typically the responsibility of the healthcare provider or a legally authorized representative. The charge nurse may not have the legal authority to provide informed consent on behalf of the client.

A. "I'm struggling with altered motor function.”. B. "I don't know why I'm feeling this way.”. C. "I just want attention from others.”. D. "I'm worried about having a serious illness.”.

Correct Answer is C

Explanation

Choice A rationale:

"I'm struggling with altered motor function.”. This statement is more in line with a description of conversion disorder or functional neurological symptom disorder, where clients may experience symptoms like paralysis or altered motor function, but these symptoms are typically not intentionally produced for attention-seeking purposes.

Choice B rationale:

"I don't know why I'm feeling this way.”. This statement does not specifically indicate a deliberate intent to falsify psychological symptoms for attention. It could be related to other emotional or psychological issues, but it doesn't directly relate to the behavior described in the question.

Choice D rationale:

"I'm worried about having a serious illness.”. This statement reflects concerns about actual medical conditions and does not align with the behavior of repeatedly falsifying psychological symptoms for attention. People with factitious disorder may feign physical symptoms but not necessarily express concerns about having a serious illness themselves. Now, let's address the last question.

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A nurse is assessing a client who has delirium.Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who repeatedly falsifies psychological symptoms to assume the role of a sick person.What statement is commonly associated with this behavior?

Correct Answer is C

Explanation

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A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?